Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains

Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes

Self-appraisal has repeatedly been shown to be inadequate as a mechanism for performance improvement. This has placed greater emphasis on understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one's self-perceptions it is important to understand how learners interpret, accept, and use feedback (or not) and the factors that influence those interpretations. 134 participants from 8 health professional training/continuing competence programs were recruited to participate in focus groups. Analyses were designed to (a) elicit understandings of the processes used by learners and physicians to interpret, accept and use (or not) data to inform their perceptions of their clinical performance, and (b) further understand the factors (internal and external) believed to influence interpretation of feedback. Multiple influences appear to impact upon the interpretation and uptake of feedback. These include confidence, experience, and fear of not appearing knowledgeable. Importantly, however, each could have a paradoxical effect of both increasing and decreasing receptivity. Less prevalent but nonetheless important themes suggested mechanisms through which cognitive reasoning processes might impede growth from formative feedback. Many studies have examined the effectiveness of feedback through variable interventions focused on feedback delivery. This study suggests that it is equally important to consider feedback from the perspective of how it is received. The interplay observed between fear, confidence, and reasoning processes reinforces the notion that there is no simple recipe for the delivery of effective feedback. These factors should be taken into account when trying to understand (a) why self-appraisal can be flawed, (b) why appropriate external feedback is vital (yet can be ineffective), and (c) why we may need to disentangle the goals of performance improvement from the goals of improving self-assessment.

Opening the black box: the patient mix of GP trainees

BACKGROUND

The variety of health problems (patient mix) that medical trainees encounter is presumed to be sufficient to master the required competencies.

AIM

To describe the patient mix of GP trainees, to study differences in patient mix between first-year and third-year GP trainees, and to investigate differences in exposure to sex-specific diseases between male and female trainees.

DESIGN AND SETTING

Prospective cohort study in Dutch primary care.

METHOD

During a 6-month period, aggregated data about International Classification of Primary Care diagnosis codes, and data on the sex and age of all contacts were collected from the electronic patient record (EPR) system.

RESULTS

Seventy-three trainees participated in this study. The mean coding percentage was 86% and the mean number of face-to-face consultations per trimester was 450.0 in the first year and 485.4 in the third year, indicating greater variance in the number of patient contacts among third-year trainees. Diseases seen most frequently were: musculoskeletal (mean per trimester = 89.2 in the first year/91.0 in the third year), respiratory (98.2/92.7) and skin diseases (89.5/96.0). Least often seen were diseases of the blood and blood-forming organs (5.3/7.2), male genital disorders (6.1/7.1), and social problems (4.3/4.2). The mean number of chronic diseases seen per trimester was 48.0 for first-year trainees and 62.4 for third-year trainees. Female trainees saw an average of 39.8 female conditions per trimester--twice as many as male trainees (mean = 21.3).

CONCLUSION

Considerable variation exists trainees in the number of patient contacts. Differences in patient mix between first- and third-year trainees seem at least partly related to year-specific learning objectives. The use of an EPR-derived educational instrument provides insight into the trainees' patient mix at both the group and the individual level. This offers opportunities for GP trainers, trainees, and curriculum designers to optimise learning when exposure may be low.

Clinical performance and skill retention after simulation-based education for nephrology fellows

We previously demonstrated that simulation-based education (SBE) improved temporary hemodialysis catheter (THDC) insertion skills by nephrology fellows. SBE, featuring deliberate practice and rigorous achievement standards, was a powerful method to enhance THDC insertion skills in nephrology fellows. However, experts have called for further research to evaluate skill transfer from the simulated environment to actual clinical care and skill retention. This is a prospective observational cohort study of THDC insertion skills. Twelve nephrology fellows from three academic centers in Chicago were evaluated using a skills checklist from July 2008 to June 2009. Simulator-trained fellows were tested after the SBE intervention and expected to meet or exceed a minimum passing score (MPS) set by an expert panel. To assess transfer of skill to clinical care, three simulator-trained fellows were assessed at 6 months on actual patient THDC insertions using the checklist. To assess retention of skill, 11 of 12 simulator-trained fellows were reassessed at 1 year using the checklist and central venous catheter simulator. Outcomes were determined by THDC insertion skill performance. Simulator-trained fellows scored similarly during 6-month THDC insertions on actual patients and immediate posttest (M = 86.2%, SD = 22.3% vs. M = 93.5%, SD = 5.3%, p = 0.32). However, 1 year after SBE, simulated THDC insertion scores were significantly lower than at immediate posttest (M = 73.4%, SD = 22.2% vs. M = 93.5%, SD = 5.3%, p = 0.01). Our results show that nephrology fellows who completed SBE displayed high levels of performance during THDC insertions on actual patients 6 months later. At 1 year, there was statistically significant skills decay. We recommend booster training at 6 months.

Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency-based training: a randomized controlled trial

OBJECTIVE

We hypothesized that novices will perform better in the operating room after simulator training to automaticity compared with traditional proficiency based training (current standard training paradigm).

BACKGROUND

Simulator-acquired skill translates to the operating room, but the skill transfer is incomplete. Secondary task metrics reflect the ability of trainees to multitask (automaticity) and may improve performance assessment on simulators and skill transfer by indicating when learning is complete.

METHODS

Novices (N = 30) were enrolled in an IRB-approved, blinded, randomized, controlled trial. Participants were randomized into an intervention (n = 20) and a control (n = 10) group. The intervention group practiced on the FLS suturing task until they achieved expert levels of time and errors (proficiency), were tested on a live porcine fundoplication model, continued simulator training until they achieved expert levels on a visual spatial secondary task (automaticity) and were retested on the operating room (OR) model. The control group participated only during testing sessions. Performance scores were compared within and between groups during testing sessions.

RESULTS

: Intervention group participants achieved proficiency after 54 ± 14 and automaticity after additional 109 ± 57 repetitions. Participants achieved better scores in the OR after automaticity training [345 (range, 0-537)] compared with after proficiency-based training [220 (range, 0-452; P < 0.001].

CONCLUSIONS

Simulator training to automaticity takes more time but is superior to proficiency-based training, as it leads to improved skill acquisition and transfer. Secondary task metrics that reflect trainee automaticity should be implemented during simulator training to improve learning and skill transfer.

Faculty staff perceptions of feedback to residents after direct observation of clinical skills

CONTEXT

Performance-based workplace assessments are increasingly important in clinical training. Given the inaccuracy of self-assessment, the provision of external feedback to residents about their clinical skills is necessary for the development of expertise. However, little is known about the processes used by faculty members in giving feedback to residents after observing them with patients. This study explores the factors that underpin faculty members' decisions regarding the feedback they give to residents after directly observing them with patients and the factors that influence how feedback is delivered.

METHODS

In 2009, 44 general internal medicine faculty staff responsible for out-patient resident teaching from 16 internal medicine residency programmes watched four videotaped scenarios and two live scenarios of standardised residents (SRs) with standardised patients and rated the SRs using the mini-clinical evaluation exercise (mini-CEX) format. Faculty staff also provided feedback to the SRs after the live encounters. After each encounter, faculty staff were individually interviewed using a semi-structured interview. Interviews were videotaped, transcribed and analysed using grounded theory methods.

RESULTS

Two broad themes were identified in faculty members' descriptions of the feedback process: variability in feedback techniques, and the factors that influence how faculty staff think and feel about delivering feedback. Multiple approaches to feedback delivery were observed. Faculty members' tensions in balancing positive and negative feedback, their own perceived self-efficacy, their perceptions of the resident's insight, receptivity, skill and potential, the faculty member-resident relationship and contextual factors impacted the feedback process.

CONCLUSIONS

The provision of feedback by faculty staff to residents after observing resident-patient interactions is a complex and dynamic process and is influenced by many factors. Understanding these cognitive and affective factors may provide insight into potential new approaches to faculty development to improve faculty staff's feedback skills and the effectiveness of their feedback.

"Blowing up the barriers" in surgical training: exploring and validating the concept of distributed simulation

OBJECTIVES

To explore face, content and construct validity of Distributed Simulation (DS), an innovative approach to low-cost, high-fidelity surgical simulation and compare technical performance in the DS with that on a standard surgical box trainer.

BACKGROUND

Immersive simulation is widely accepted as an important modality for surgical education. However, access and cost limit the uptake of full-scale simulation training. DS is a portable, simulated clinical environment aiming at widening access to immersive simulation.

METHODS

Ten novice and 10 expert surgeons performed a laparoscopic cholecystectomy on a porcine model in the DS and on a box trainer. Face and content validity were measured using 6-point Likert-type questionnaires. Construct validity was rated using the Objective Structured Assessment of Technical Skills (OSATS). Comparison of technical performance between DS and box trainer was measured using the Wilcoxon test.

RESULTS

Face validity was rated as 5.1 (SD = 0.54) by novices and 4.8 (SD = 0.64) by experts.Content validity was rated as 5.2 (SD = 0.40) by novices and 5.1 (SD = 0.56) by experts. Experts performed significantly better than novices in the DS (16.3 vs. 27.3, P < 0.001) demonstrating construct validity. Experts' technical performance did not differ between DS and box trainer (26.5 vs. 27.3, P > 0.84) whereas novices performed better on the box trainer (19.8 vs. 16.3, P < 0.01). Qualitative data analysis demonstrated that surgeons felt able to behave as if in a real operating room (OR).

CONCLUSION

DS offers a valid, low-cost, accessible environment for training and assessing surgeons. This approach has major implications for surgical education and for the widespread implementation of immersive simulation at a time of increasing financial austerity.

Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery

BACKGROUND AND PURPOSE

Surgery is a high-stakes "performance." Yet, unlike athletes or musicians, surgeons do not engage in routine "warm-up" exercises before "performing" in the operating room. We study the impact of a preoperative warm-up exercise routine (POWER) on surgeon performance during laparoscopic surgery.

MATERIALS AND METHODS

Serving as their own controls, each subject performed two pairs of laparoscopic cases, each pair consisting of one case with POWER (+POWER) and one without (-POWER). Subjects were randomly assigned to +POWER or -POWER for the initial case of each pairing, and all cases were performed ≥ 1 week apart. POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer. For each case, cognitive, psychomotor, and technical performance data were collected during two different tasks: mobilization of the colon (MC) and intracorporeal suturing and knot tying (iSKT). Statistical analysis was performed using SYSTAT v11.0.

RESULTS

A total of 28 study cases (14+POWER, 14-POWER) were performed by seven different subjects. Cognitive and psychomotor performance (attention, distraction, workload, spatial reasoning, movement smoothness, posture stability) were found to be significantly better in the +POWER group (P ≤ 0.05) and technical performance, as scored by two blinded laparoscopic experts, was found to be better in the +POWER group for MC (P=0.04) but not iSKT (P=0.92). Technical scores demonstrated excellent reliability using our assessment tool (Cronbach ∝=0.88). Subject performance during POWER was also found to correlate with intraoperative performance scores.

CONCLUSIONS

Urologic trainees who perform a POWER approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive, psychomotor, and technical performance.

Identifying early warning signs for diagnostic errors in primary care: a qualitative study

OBJECTIVE

We investigate the mechanisms of diagnostic error in primary care consultations to detect warning signs for possible error. We aim to identify places in the diagnostic reasoning process associated with major risk indicators.

DESIGN

A qualitative study using semistructured interviews with open-ended questions.

SETTING

A 2-month study in primary care conducted in Oxfordshire, UK.

PARTICIPANTS

We approached about 25 experienced general practitioners by email or word of mouth, 15 volunteered for the interviews and were available at a convenient time.

INTERVENTION

Interview transcripts provided 45 cases of error. Three researchers searched these independently for underlying themes in relation to our conceptual framework.

OUTCOME MEASURES

Locating steps in the diagnostic reasoning process associated with major risk of error and detecting warning signs that can alert clinicians to increased risk of error.

RESULTS

Initiation and closure of the cognitive process are most exposed to risk of error. Cognitive biases developed early in the process lead to errors at the end. These warning signs can be used to alert clinicians to the increased risk of diagnostic error. Ignoring red flags or critical cues was related to processes being biased through the initial frame, but equally well, it could be explained by knowledge gaps.

CONCLUSIONS

Cognitive biases developed at the initial framing of the problem relate to errors at the end of the process. We refer to these biases as warning signs that can alert clinicians to the increased risk of diagnostic error. We conclude that lack of knowledge is likely to be an important factor in diagnostic error. Reducing diagnostic errors in primary care should focus on early and systematic recognition of errors including near misses, and a continuing professional development environment that promotes reflection in action to highlight possible causes of process bias and of knowledge gaps.

Reaching the limits of mandated self-reporting: clinical logbooks do not predict clerkship performance

BACKGROUND

Logbooks are used by US medical schools to evaluate curricular objectives and meet accreditation requirements, but research supporting their utility is conflicting.

AIMS

The goal of our study was to examine the relationship between volume of clinical rotation experiences as reported in a logbook and clerkship grades within a longitudinal integrated clerkship.

METHODS

We conducted a retrospective cohort study of third-year (clinical) medical students during academic year 2008-2009. We tracked student entries in a pocket-sized logbook (number of clinical encounters per clerkship, total number of exams, and procedures over the academic year). We performed correlation analyses between logbook entries and clerkship grades.

RESULTS

We enrolled 36 students, who reported a total of 2992 encounters, 2262 exams, and 2342 procedures. Correlation coefficients between volume of clinical experience and clerkship grades were less than 0.4, indicating low correlation. We found borderline statistical significance for the Neurology, OB/Gyn, and Surgery clerkships. Sensitivity analyses showed little correlation between low-reporting activity and clerkship grades.

CONCLUSIONS

Even within an integrated longitudinal clerkship framework, our findings are consistent with previous studies showing a negligible relationship between logbooks as an educational process measure and how they relate to educational outcomes.

Teaching musculoskeletal clinical skills to medical trainees and physicians: a Best Evidence in Medical Education systematic review of strategies and their effectiveness: BEME Guide No. 18

BACKGROUND

Musculoskeletal (MSK) complaints make up 12-20% of primary health visits and are a source of significant expenditures and morbidity. Despite this, MSK examination is an area of weakness among practising physicians. Several studies have highlighted the need for increased MSK physical exam teaching. However, increased teaching time alone does not guarantee improvement in these skills. Thus, we aimed to identify interventions that are effective in promoting transfer of MSK clinical skills.

METHODS

The review protocol was approved by the Best Evidence in Medical Education (BEME) organization. A comprehensive search was conducted and systematic review methods were applied. Data were not pooled statistically due to heterogeneity.

RESULTS

About 5089 titles were screened; 24 studies were included. Eighteen of 24 studies focused on undergraduate medical education. Five of nine studies favoured patient educator. Five of six studies favoured interactive small groups, two of four studies favoured computer-assisted learning, and two of two studies favoured peer learning. Individual studies demonstrated effectiveness of reminder sheets and Gait Arms Legs Spine teaching, respectively.

CONCLUSIONS

This study supports the use of different instructional methods that engage learners and provide meaningful learning contexts. The majority of the studies support patient educators and interactive small group teaching.

Quality evaluation reports: Can a faculty development program make a difference?

BACKGROUND

The quality of medical student and resident clinical evaluation reports submitted by rotation supervisors is a concern. The effectiveness of faculty development (FD) interventions in changing report quality is uncertain.

AIMS

This study assessed whether faculty could be trained to complete higher quality reports.

METHOD

A 3-h interactive program designed to improve evaluation report quality, previously developed and tested locally, was offered at three different Canadian medical schools. To assess for a change in report quality, three reports completed by each supervisor prior to the workshop and all reports completed for 6 months following the workshop were evaluated by three blinded, independent raters using the Completed Clinical Evaluation Report Rating (CCERR): a validated scale that assesses report quality.

RESULTS

A total of 22 supervisors from multiple specialties participated. The mean CCERR score for reports completed after the workshop was significantly higher (21.74 ± 4.91 versus 18.90 ± 5.00, p = 0.02).

CONCLUSIONS

This study demonstrates that this FD workshop had a positive impact upon the quality of the participants' evaluation reports suggesting that faculty have the potential to be trained with regards to trainee assessment. This adds to the literature which suggests that FD is an important component in improving assessment quality.

Twelve tips for giving feedback effectively in the clinical environment

BACKGROUND

Feedback is an essential element of the educational process for clinical trainees. Performance-based feedback enables good habits to be reinforced and faulty ones to be corrected. Despite its importance, most trainees feel that they do not receive adequate feedback and if they do, the process is not effective.

AIMS AND METHODS

The authors reviewed the literature on feedback and present the following 12 tips for clinical teachers to provide effective feedback to undergraduate and graduate medical trainees. In most of the tips, the focus is the individual teacher in clinical settings, although some of the suggestions are best adopted at the institutional level.

RESULTS

Clinical educators will find the tips practical and easy to implement in their day-to-day interactions with learners. The techniques can be applied in settings whether the time for feedback is 5 minutes or 30 minutes.

CONCLUSIONS

Clinical teachers can improve their skills for giving feedback to learners by using the straightforward and practical tools described in the subsequent sections. Institutions should emphasise the importance of feedback to their clinical educators, provide staff development and implement a mechanism by which the quantity and quality of feedback is monitored.

Clinical decision making in a high-risk primary care environment: a qualitative study in the UK

OBJECTIVE

Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment.

DESIGN

Semi-structured interviews using open-ended questions.

SETTING

A 2-month qualitative interview study conducted in Oxfordshire, UK.

PARTICIPANTS

21 GPs working in OOH primary care.

RESULTS

The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of 'fire fighting'. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness.

CONCLUSIONS

The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting.

A study of depression and anxiety, general health, and academic performance in three cohorts of veterinary medical students across the first three semesters of veterinary school

This study builds on previous research on predictors of depression and anxiety in veterinary medical students and reports data on three veterinary cohorts from two universities through their first three semesters of study. Across all three semesters, 49%, 65%, and 69% of the participants reported depression levels at or above the clinical cut-off, suggesting a remarkably high percentage of students experiencing significant levels of depression symptoms. Further, this study investigated the relationship between common stressors experienced by veterinary students and mental health, general health, and academic performance. A factor analysis revealed four factors among stressors common to veterinary students: academic stress, transitional stress, family-health stress, and relationship stress. The results indicated that both academic stress and transitional stress had a robust impact on veterinary medical students' well-being during their first three semesters of study. As well, academic stress negatively impacted students in the areas of depression and anxiety symptoms, life satisfaction, general health, perception of academic performance, and grade point average (GPA). Transitional stress predicted increased depression and anxiety symptoms and decreased life satisfaction. This study helped to further illuminate the magnitude of the problem of depression and anxiety symptoms in veterinary medical students and identified factors most predictive of poor outcomes in the areas of mental health, general health, and academic performance. The discussion provides recommendations for considering structural changes to veterinary educational curricula to reduce the magnitude of academic stressors. Concurrently, recommendations are suggested for mental health interventions to help increase students' resistance to environmental stressors.

A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills

BACKGROUND

Infant lumbar puncture (LP) is mandated by the Accreditation Council for Graduate Medical Education for all pediatric trainees. Current training usually involves the apprenticeship model of "see one, do one, teach one" where a trainee's first LP attempt occurs in a high-stakes environment. Simulation training promotes skill development in a safe environment before patient contact.

OBJECTIVE

To demonstrate that deliberate practice simulation-based training after audiovisual training (AV) improves infant LP skills compared with a control group receiving AV training only.

DESIGN/METHODS

This was a randomized trial of simulation-based training + AV versus AV only for pediatric residents. On enrollment, the subjects' infant LP skills were evaluated through their performance on a simulator. A questionnaire and brief quiz were administered to collect information on the subjects' infant LP experience, knowledge, and confidence. All subjects viewed an educational AV presentation. The intervention group went on to participate in a simulation-based deliberate practice session on the infant LP simulator while the control group did not. Our primary outcome was self-reported clinical success on the first infant LP after training. Secondary outcomes were rates of traumatic clinical LPs, infant LP skills (measured via observed structured clinical examinations on the simulator 6 months after training), and change in participants' knowledge and confidence.

RESULTS

Fifty-one residents reported 32 clinical encounters. Sixteen of 17 subjects (94%) in the intervention group who performed a clinical infant LP obtained cerebrospinal fluid compared with 7 of 15 subjects (47%) in the control group (difference = 47%; 95% CI = 16%-70%). There was no difference between groups at 6 months on observed structured clinical examination performance, knowledge, or confidence.

CONCLUSIONS

Participation in a simulation-based deliberate practice intervention can improve infant LP skill.

Geritalk: communication skills training for geriatric and palliative medicine fellows

Expert communication is essential to high-quality care for older patients with serious illness. Although the importance of communication skills is widely recognized, formal curricula for teaching communication skills to geriatric and palliative medicine fellows is often inadequate or unavailable. The current study drew upon the educational principles and format of an evidence-based, interactive teaching method to develop an intensive communication skills training course designed specifically to address the common communication challenges that geriatric and palliative medicine fellows face. The 2-day retreat, held away from the hospital environment, included large-group overview presentations, small-group communication skills practice, and development of future skills practice commitment. Faculty received in-depth training in small-group facilitation techniques before the course. Geriatric and palliative medicine fellows were recruited to participate in the course and 100% (n = 18) enrolled. Overall satisfaction with the course was very high (mean 4.8 on a 5-point scale). After the course, fellows reported an increase in self-assessed preparedness for specific communication challenges (mean increase 1.4 on 5-point scale, P < .001). Two months after the course, fellows reported a high level of sustained skills practice (mean 4.3 on 5-point scale). In sum, the intensive communication skills program, customized for the specific needs of geriatric and palliative medicine fellows, improved fellows' self-assessed preparedness for challenging communication tasks and provided a model for ongoing deliberate practice of communication skills.

Education in airway management

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

An evidence-based approach to airway management: is there a role for clinical practice guidelines?

Complications arising out of airway management represent an important cause of anaesthesia-associated morbidity and mortality. Anaesthetic practice itself can lead to preventable harm, a particular example being persistent attempts at direct laryngoscopy, that results in delay in employing alternative strategies (or devices) when intubation is difficult. When patients are injured, expert review is called upon and often concludes that airway management provided by the anaesthetists was substandard. Many training programmes do not offer their trainees structured or organised teaching in airway management and many trainees probably enter practice with limited skills to deal with difficult airways. The literature on the management of the difficult airway in anaesthesia practice (especially as it relates to new technology and salvage strategies) is expanding rapidly. New technologies and practised response algorithms may be helpful in the management of the difficult airway, reducing the potential for adverse patient outcomes. Specialist societies and national interest groups can play an important role by critically reviewing and then applying the evidence base to generate clinical practice guidelines. The recommendations contained in such guidelines should be based on the most current evidence and they should be reviewed regularly for their content and continued relevance.

Multi-center development and testing of a simulation-based cardiovascular assessment curriculum for advanced practice nurses

Cardiovascular assessment skills are deficient among advanced practice nursing students, and effective instructional methods to improve assessment skills are needed. The purpose of this study was to develop, implement, and evaluate outcomes of a cardiovascular assessment curriculum for advanced practice nurses at four institutions. Each institution used a one-group pre-to-post-intervention design. Educational interventions included faculty-led, simulation-based case presentations using the Harvey cardiopulmonary patient simulator (CPS), and independent learning sessions using the CPS and a multimedia, computer-based CD-ROM program. Outcome measures included a 31-item cognitive written exam, a 13-item skills checklist used in each of a three-station objective structured clinical exam, learner self-efficacy and satisfaction survey, instructor satisfaction and self-efficacy survey, and a participant logbook to record practice time using the self-learning materials. Thirty-six students who received the simulation-based training showed statistically significant pre-to-post-test improvement in cognitive knowledge and cardiovascular assessment skills.

Review article: simulation in anesthesia: state of the science and looking forward

PURPOSE

Within the field of anesthesia, simulation has been used as a tool for training and assessment for over 30 years. The purpose of this review is to evaluate the state of the science in terms of its effectiveness as an approach to both training and assessment in anesthesia. Articles in the area of simulation and anesthesia published up to and including 2011 were reviewed for inclusion in this narrative review.

PRINCIPAL FINDINGS

Simulation-based training is generally well received by participants, it can lead to improved performance in subsequent simulation events, and some transfer of learning to the clinical setting is evident. There is also some early evidence that well-designed performance assessments could have the required reliability and validity to support high-stakes examinations. However, further work is needed in order to set standards and establish the predictive validity to support such assessments.

CONCLUSION

For simulation to realize its potential impact, further research is needed to understand how to optimize this modality of learning more effectively, how to transfer knowledge of research findings to practice, and also how to broaden the simulation modalities used in anesthesia. In future, the optimal use of simulation will depend on a clear understanding of what can and cannot be accomplished with simulation and its various modalities.

Review article: closing the research gap at the interface of learning and clinical practice

PURPOSE

The dialogue at the interface of education and clinical practice highlights areas of critical importance to the development of new approaches for educating anesthesiologists. The purpose of this article is to examine the literature on education and acquisition of competence in three areas relevant to the interface of learning and clinical practice, with the aim to suggest a research agenda that adds to the evidence on preparing physicians for independent practice. The three areas are: 1) transitions across the continuum of education; 2) the effect of reductions in hours of clinical training on competence; and 3) efforts to incorporate the competencies and CanMEDS roles into teaching and evaluation.

PRINCIPAL FINDINGS

Fifty-six articles relevant to one or more of the themes were identified in the review, including 21 studies of transitions (in, during, and after residency education), 19 studies on the effects of duty hour limits on residents' acquisition of competence, and 16 articles that assessed competency-based teaching and assessment in anesthesiology. Overall, the findings suggested a relative paucity of scientific evidence and a need for research and the development of new scientific theory. Studies generally treated one of the themes in isolation, while in actuality they interact to produce optimal as well as suboptimal learning situations, while medical education research often is limited by small samples, brief follow-up, and threats to validity. This suggests a "research gap" where editorials and commentaries have moved ahead of an evidence base for education. Promising areas for research include preparation for care deemed important by society, work to apply knowledge about the development of expertise in other disciplines to medicine, and ways to embed the competencies in teaching and evaluation more effectively.

CONCLUSION

Closing the research gap in medical education will require clear direction for future work. The starting point, at an institution or nationally, is dialogue within the specialty to achieve consensus on some of the most pressing questions.

Review article: new directions in medical education related to anesthesiology and perioperative medicine

PURPOSE

We aim to provide a broad overview of current key issues in anesthesiology education to encourage both "clinician teachers" and "clinician educators" in academic health centres to consider how medical educational theory can inform their own practice.

PRINCIPAL FINDINGS

Evolving contextual issues, such as work-hour reform and the patient safety movement, necessitate innovative approaches to anesthesiology education. There is a substantial amount of relevant literature from other disciplines, such as sociology, psychology, and human factors research, using methodologies that are often unfamiliar to most clinicians. Recurring themes include the increasing use of simulation-based education, the importance of faculty development, challenges in teaching and assessing the non-medical expert roles, and the promise of team training and interprofessional education. Interdisciplinary collaborations are likely key to answering pressing questions in anesthesiology education, and a greater understanding of qualitative and mixed methods research will allow a broader range of questions to be answered. Simulation offers the opportunity to learn from failures without exposing patients to risk and brings the challenge of integrating innovations into existing curricula. Interprofessional education allows learning in the teams that will work together; even so, it needs to be prioritized to overcome logistical barriers. The challenges of introducing a competency-based curriculum have resulted in hybrid systems where elements of competency-based medical education have been combined with traditional apprenticeship curricula. The value of faculty development to encourage even simple measures, such as establishing learning objectives and discussing these with trainees, cannot be over-emphasized. Key issues in assessment include the need to evaluate multiple levels of performance in a cohesive system of assessment and the need to identify the unintended consequences of assessment.

CONCLUSIONS

We have identified a number of key themes and challenges for anesthesiology education. This discussion will continue in greater depth in individual articles in this issue so as to promote further interest in a growing body of literature that is relevant to anesthesiology education.

Design and effectiveness of a required pre-clinical simulation-based curriculum for fundamental clinical skills and procedures

BACKGROUND

For more than 20 years, medical literature has increasingly documented the need for students to learn, practice and demonstrate competence in basic clinical knowledge and skills. In 2001, the Louisiana State University Health Science Centers (LSUHSC) School of Medicine - New Orleans replaced its traditional Introduction in to Clinical Medicine (ICM) course with the Science and Practice of Medicine (SPM) course. The main component within the SPM course is the Clinical Skills Lab (CSL). The CSL teaches 30 plus skills to all pre-clinical medical students (Years 1 and 2).

METHODS

Since 2002, an annual longitudinal evaluation questionnaire was distributed to all medical students targeting the skills taught in the CSL. Students were asked to rate their self- confidence (Dreyfus and Likert-type) and estimate the number of times each clinical skill was performed (clinically/non-clinically). Of the 30 plus skills taught, 8 were selected for further evaluation.

RESULTS

An analysis was performed on the eight skills selected to determine the effectiveness of the CSL. All students that participated in the CSL reported a significant improvement in self-confidence and in number performed in the clinically/non-clinically setting when compared to students that did not experience the CSL. For example, without CSL training, the percentage of students reported at the end of their second year self-perceived expertise as "novice" ranged from 21.4% (CPR) to 84.7% (GU catheterization). Students who completed the two-years CSL, only 7.8% rated their self-perceived expertise at the end of the second year as "novice" and 18.8% for GU catheterization.

CONCLUSION

The CSL design is not to replace real clinical patient experiences. It's to provide early exposure, medial knowledge, professionalism and opportunity to practice skills in a patient free environment.

The role of deliberate practice in the acquisition of clinical skills

BACKGROUND

The role of deliberate practice in medical students' development from novice to expert was examined for preclinical skill training.

METHODS

Students in years 1-3 completed 34 Likert type items, adapted from a questionnaire about the use of deliberate practice in cognitive learning. Exploratory factor analysis and reliability analysis were used to validate the questionnaire. Analysis of variance examined differences between years and regression analysis the relationship between deliberate practice and skill test results.

RESULTS

875 students participated (90%). Factor analysis yielded four factors: planning, concentration/dedication, repetition/revision, study style/self reflection. Student scores on 'Planning' increased over time, score on sub-scale 'repetition/revision' decreased. Student results on the clinical skill test correlated positively with scores on subscales 'planning' and 'concentration/dedication' in years 1 and 3, and with scores on subscale 'repetition/revision' in year 1.

CONCLUSIONS

The positive effects on test results suggest that the role of deliberate practice in medical education merits further study. The cross-sectional design is a limitation, the large representative sample a strength of the study. The vanishing effect of repetition/revision may be attributable to inadequate feedback. Deliberate practice advocates sustained practice to address weaknesses, identified by (self-)assessment and stimulated by feedback. Further studies should use a longitudinal prospective design and extend the scope to expertise development during residency and beyond.

Evidence-based practice profiles of physiotherapists transitioning into the workforce: a study of two cohorts

BACKGROUND

Training in the five steps of evidence-based practice (EBP) has been recommended for inclusion in entry-level health professional training. The effectiveness of EBP education has been explored predominantly in the medical and nursing professions and more commonly in post-graduate than entry-level students. Few studies have investigated longitudinal changes in EBP attitudes and behaviours. This study aimed to assess the changes in EBP knowledge, attitudes and behaviours in entry-level physiotherapy students transitioning into the workforce.

METHODS

A prospective, observational, longitudinal design was used, with two cohorts. From 2008, 29 participants were tested in their final year in a physiotherapy program, and after the first and second workforce years. From 2009, 76 participants were tested in their final entry-level and first workforce years. Participants completed an Evidence-Based Practice Profile questionnaire (EBP2), which includes self-report EBP domains [Relevance, Terminology (knowledge of EBP concepts), Confidence, Practice (EBP implementation), Sympathy (disposition towards EBP)]. Mixed model analysis with sequential Bonferroni adjustment was used to analyse the matched data. Effect sizes (ES) (95% CI) were calculated for all changes.

RESULTS

Effect sizes of the changes in EBP domains were small (ES range 0.02 to 0.42). While most changes were not significant there was a consistent pattern of decline in scores for Relevance in the first workforce year (ES -0.42 to -0.29) followed by an improvement in the second year (ES +0.27). Scores in Terminology improved (ES +0.19 to +0.26) in each of the first two workforce years, while Practice scores declined (ES -0.23 to -0.19) in the first year and improved minimally in the second year (ES +0.04). Confidence scores improved during the second workforce year (ES +0.27). Scores for Sympathy showed little change.

CONCLUSIONS

During the first two years in the workforce, there was a transitory decline in the self-reported practice and sense of relevance of EBP, despite increases in confidence and knowledge. The pattern of progression of EBP skills beyond these early professional working years is unknown.

Feedback in the emergency medicine clerkship

OBJECTIVE

Feedback is a technique used in medical education to help develop and improve clinical skills. A comprehensive review article specifically intended for the emergency medicine (EM) educator is lacking, and it is the intent of this article to provide the reader with an in-depth, up-to-date, and evidence-based review of feedback in the context of the EM clerkship.

METHODS

The review article is organized in a progressive manner, beginning with the definition of feedback, the importance of feedback in medical education, the obstacles limiting the effective delivery of feedback, and the techniques to overcome these obstacles then follows. The article concludes with practical recommendations to implement feedback in the EM clerkship. To advance the literature on feedback, the concept of receiving feedback is introduced.

RESULTS

The published literature regarding feedback is limited but generally supportive of its importance and effectiveness. Obstacles in the way of feedback include time constraints, lack of direct observation, and fear of negative emotional responses from students. Feedback should be timely, expected, focused, based on first-hand data, and limited to behaviors that are remediable. Faculty development and course structure can improve feedback in the EM clerkship. Teaching students to receive feedback is a novel educational technique that can improve the feedback process.

CONCLUSION

Feedback is an important educational technique necessary to improve clinical skills. Feedback can be delivered effectively in the EM clerkship.

Year one outcomes assessment of a masters suturing and knot-tying program for surgical interns

PURPOSE

We implemented and evaluated the outcomes of a proficiency-based program to enhance basic suturing and knot-tying skills in surgical interns.

METHODS

A suturing and knot-tying "masters program" was implemented for 9 surgical interns. Assessment consisted of timed and videotaped technical performance (TP) of 6 suturing (simple interrupted, subcuticular, and vertical mattress) and tying tasks (1-handed, 2-handed, and tie on pass) preinstruction (baseline) and at 4 months. Feedback and remediation were done after 4 months, and interns were retested until goals were met. TP was scored on a 1-5 scale (1 = novice, 3 = proficient, and 5 = expert). The results were compared with 6 end of PGY2 year residents and rotation evaluations, case numbers, and American Board of Surgery In-Training Examination (ABSITE) scores. The data are mean ± standard deviation (SD); statistical analysis was by 1-way ANOVA, Kruskal-Wallis test, and Pearson correlation.

RESULTS

The total combined task times improved significantly from initial (1289 ± 301 seconds) to final assessment (770 ± 139 seconds, p = 0.0003) and between 4-month assessment (1092 ± 253 seconds) and final assessment (p = 0.0237), but not baseline to 4-month assessment (p = 0.213). Final TP scores were improved significantly (baseline, 1.87 ± 0.81; 4-month assessment, 2.63 ± 0.75; and final assessment 3.51 ± 0.39 [p < 0.001]. All interns reached proficiency on 6/6 tasks but not until 10.1 months (range, 4-12 months) and 2.4 assessment sessions (range, 1-3). No significant differences in final total task times or TP scores were found between interns (770 ± 139 seconds and TP, 3.51 ± 0.39) and end of PGY-2 residents (677 ± 109 seconds and TP, 3.6 ± 0.43). The total task time and rotation technical comments were associated significantly, but TP scores, case numbers, and ABSITE scores were not.

CONCLUSIONS

Training, feedback, and remediation are necessary to reach proficiency in basic suturing and knot tying. This program provides an objective assessment of interns' skills not discernible by conventional measures.

Expertise in prehospital endotracheal intubation by emergency medicine physicians-Comparing 'proficient performers' and 'experts'

BACKGROUND

Training requirements to perform safe prehospital endotracheal intubation (ETI) are not clearly known. This study aimed to determine differences in ETI performance between 'proficient performers' and 'experts' according to the Dreyfus & Dreyfus framework of expertise. As a model for 'proficient performers' EMS physicians with a clinical background in internal medicine were compared to EMS physicians with a background in anaesthesiology as a model for 'experts'.

METHODS

Over a one-year period all ETIs performed by the EMS physicians of our institution were prospectively evaluated. 'Proficient performers' and 'experts' were compared regarding incidence of difficult ETI, ability to predict difficult ETI, and decision for ETI.

RESULTS

Mean years of professional experience were similar between the physician groups, but the median ETI experience differed significantly with 18/year for 'proficients' and 304/year for 'experts' (p<0.001). 'Proficient performers' intubated 130 of their 2170 treated patients (6.0%), while 'experts' did so in 146 of 1809 cases (8.1%, p=0.01 for difference). The incidence of difficult ETI was 17.7% for 'proficient performers', and 8.9% for 'experts' (p<0.05). In 4 cases ETI was impossible, all managed by 'proficient performers', but all patients could be ventilated sufficiently. Unexpected difficult ETI occurred in 6.1% for 'proficient performers', and 2.0% for 'experts' (p=0.08).

CONCLUSIONS

In a prehospital setting 'expert' status was associated with a significantly lower incidence of 'difficult ETI' and a higher proportion of ETI decisions. In addition, ability to predict difficult ETI was higher, although non-significant. There was no difference in the incidence of impossible ventilation.

Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial

PURPOSE

The purpose of this study is to determine the effect of simulation-based education on the knowledge and skills of internal medicine residents in the medical intensive care unit (MICU).

METHODS AND MATERIALS

From January 2009 to January 2010, 60 first-year residents at a tertiary care teaching hospital were randomized by month of rotation to an intervention group (simulator-trained, n = 26) and a control group (traditionally trained, n = 34). Simulator-trained residents completed 4 hours of simulation-based education before their medical intensive care unit (MICU) rotation. Topics included circulatory shock, respiratory failure, and mechanical ventilation. After their rotation, residents completed a standardized bedside skills assessment using a 14-item checklist regarding respiratory mechanics, ventilator settings, and circulatory parameters. Performance of simulator-trained and traditionally trained residents was compared using a 2-tailed independent-samples t test.

RESULTS

Simulator-trained residents scored significantly higher on the bedside skills assessment compared with traditionally trained residents (82.5% ± 10.6% vs 74.8% ± 14.1%, P = .027). Simulator-trained residents were highly satisfied with the simulation curriculum.

CONCLUSIONS

Simulation-based education significantly improved resident knowledge and skill in the MICU. Knowledge acquired in the simulated environment was transferred to improved bedside skills caring for MICU patients. Simulation-based education is a valuable adjunct to standard clinical training for residents in the MICU.

Validity and Efficacy of a Pediatric Airway Foreign Body Training Course in Resident Education

Objectives:

We evaluated the validity and efficacy of a pediatric airway foreign body simulation for otolaryngology resident training.

Methods:

We created a course using a high-fidelity toddler mannequin designed to instruct and evaluate otolaryngology residents in pediatric airway foreign body management. Seven junior and 5 senior residents participated. Their performance was evaluated by 2 observers using an Objective Structured Assessment of Technical Skills (OSATS) instrument.

Results:

By the third trial, all junior and senior residents scored a proficiency level of “independent without errors” or “independent and efficient,” and the performance of the junior residents was not different from that of the senior residents. After completing the course, the junior residents self-rated their abilities as commensurate with those of a senior resident, and senior residents rated themselves capable of performing foreign body extraction without supervision. All participants felt that the course and simulator had good overall realism and a realistic feel, demonstrating face validity. Perhaps most importantly, the residents' highest ratings were for “facilitated management of complications” and “facilitated working with the operating room team” — areas difficult to teach during live surgical procedures.

Conclusions:

This pediatric airway foreign body course using a high-fidelity simulator has face and construct validity, and results in statistically improved performance and self-evaluation of all participants.

Opening the black box of clinical skills assessment via observation: a conceptual model

OBJECTIVES

This study was intended to develop a conceptual framework of the factors impacting on faculty members' judgements and ratings of resident doctors (residents) after direct observation with patients.

METHODS

In 2009, 44 general internal medicine faculty members responsible for out-patient resident teaching in 16 internal medicine residency programmes in a large urban area in the eastern USA watched four videotaped scenarios and two live scenarios of standardised residents engaged in clinical encounters with standardised patients. After each, faculty members rated the resident using a mini-clinical evaluation exercise and were individually interviewed using a semi-structured interview. Interviews were videotaped, transcribed and analysed using grounded theory methods.

RESULTS

Four primary themes that provide insights into the variability of faculty assessments of residents' performance were identified: (i) the frames of reference used by faculty members when translating observations into judgements and ratings are variable; (ii) high levels of inference are used during the direct observation process; (iii) the methods by which judgements are synthesised into numerical ratings are variable, and (iv) factors external to resident performance influence ratings. From these themes, a conceptual model was developed to describe the process of observation, interpretation, synthesis and rating.

CONCLUSIONS

It is likely that multiple factors account for the variability in faculty ratings of residents. Understanding these factors informs potential new approaches to faculty development to improve the accuracy, reliability and utility of clinical skills assessment.

Key challenges in simulated patient programs: an international comparative case study

BACKGROUND

The literature on simulated or standardized patient (SP) methodology is expanding. However, at the level of the program, there are several gaps in the literature. We seek to fill this gap through documenting experiences from four programs in Australia, Canada, Switzerland and the United Kingdom. We focused on challenges in SP methodology, faculty, organisational structure and quality assurance.

METHODS

We used a multiple case study method with cross-case synthesis. Over eighteen months during a series of informal and formal interactions (focused meetings and conference presentations) we documented key characteristics of programs and drew on secondary document sources.

RESULTS

Although programs shared challenges in SP methodology they also experienced differences. Key challenges common to programs included systematic quality assurance and the opportunity for research. There were differences in the terminology used to describe SPs, in their recruitment and training. Other differences reflected local conditions and demands in organisational structure, funding relationships with the host institution and national trends, especially in assessments.

CONCLUSION

This international case study reveals similarities and differences in SP methodology. Programs were highly contextualised and have emerged in response to local, institutional, profession/discipline and national conditions. Broader trends in healthcare education have also influenced development. Each of the programs experienced challenges in the same themes but the nature of the challenges often varied widely.

Intensive medical student involvement in short-term surgical trips provides safe and effective patient care: a case review

BACKGROUND

The hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience.

FINDINGS

Over three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%). Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained.

DISCUSSION

This demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.

Training gaps for pediatric residents planning a career in primary care: a qualitative and quantitative study

BACKGROUND

Resident training in pediatrics currently entails similar training for all residents in a fragmented curriculum with relatively little attention to the career plans of individual residents.

OBJECTIVES

To explore strengths and gaps in training for residents planning a career in primary care pediatrics and to present strategies for addressing the gaps.

METHODS

Surveys were sent to all graduates of the University of Colorado Denver Pediatric Residency Program (2003-2006) 3 years after completion of training. Respondents were asked to evaluate aspects of their training, using a 5-point Likert scale and evaluating each item ranging from "not at all well prepared" to "extremely well prepared" for their future career. In addition, focus groups were conducted with practitioners in 8 pediatric practices in Colorado. Sessions were transcribed and hand coded by 2 independent coders.

RESULTS

Survey data identified training in behavior and development (mean score, 3.72), quality improvement and patient safety strategies (mean, 3.57), and practice management (mean, 2.46) as the weakest aspects of training. Focus groups identified deficiencies in training in mental health, practice management, behavioral medicine, and orthopedics. Deficiencies noted in curriculum structure were lack of residents' long-term continuity of relationships with patients; the need for additional training in knowledge, skills, and attitudes needed for primary care (perhaps even a fourth year of training); and a training structure that facilitates greater resident autonomy to foster development of clinical capability and self-confidence.

CONCLUSIONS

Important gaps were identified in the primary care training of pediatric residents. These data support the need to develop more career-focused training.

Putting the expert together again

CONTEXT

The study of expertise in medical education has a long history of success. Researchers have identified and elaborated on many dimensions of expert performance. In part, this success has derived from researchers' ability to effectively isolate the dimensions and explore each separately. Although this deconstruction of the expert has been successful, the need to recombine the dimensions of expertise as part of an integrated construct of expert practice has recently become an increasingly evident imperative in health professions education.

METHODS

The aims of this paper are first to explore dimensions of expert practice as they are expressed in the expertise literature; secondly, to describe more recent programmes of research that have tried to elaborate on how experts integrate these various dimensions during daily practice, and, finally, to examine the potential implications of research exploring how experts integrate their own knowledge and skills with the affordances of the environment in which they work.

RESULTS AND CONCLUSIONS

There are both challenges and opportunities in elaborating an integrated discourse on expertise. Exploring directions for research related to this integrated construction of the practising expert may add an important dimension to our educational repertoire.

Internal medicine residency redesign: proposal of the Internal Medicine Working Group

Concerned with the quality of internal medicine training, many leaders in the field assembled to assess the state of the residency, evaluate the decline in interest in the specialty, and create a framework for invigorating the discipline. Although many external factors are responsible, we also found ourselves culpable: allowing senior role models to opt out of important training activities, ignoring a progressive atrophy of bedside skills, and focusing on lock-step curricula, lectures, and compiled diagnostic and therapeutic strategies. The group affirmed its commitment to a vision of internal medicine rooted in science and learned with mentors at the bedside. Key factors for new emphasis include patient-centered small group teaching, greater incorporation of clinical epidemiology and health services research, and better schedule control for trainees. Because previous proposals were weakened by lack of evidence, we propose to organize the Cooperative Educational Studies Group, a pool of training programs that will collect a common data set describing their programs, design interventions to be tested rigorously in multi-methodological approaches, and at the same time produce knowledge about high-quality practice.

Deliberate practice of motor skills in nursing education: CPR as exemplar

Our study explored the effects of deliberate practice on the retention ofcardiopulmonary resuscitation (CPR) psychomotor skills among nursing students. The practice sessions were short, six minutes a session one time a month. Differences in performance between students who had deliberate practice and a control group, with no practice beyond the initial training, were compared every three months for one year. The intervention group performed better than the control over the 12 months. There is a need in nursing education for deliberate practice of relevant and high-use skills for students to improve their performance and gradually develop their expertise.

Teaching subcuticular suturing to medical students: video versus expert instructor feedback

OBJECTIVE

Given limitations in surgical educational resources, more efficient teaching methods are needed. We sought to evaluate 3 strategies for improving skills in subcuticular suturing-practice with an instructional video, practice with expert instructor supervision, and independent practice.

DESIGN

Fifty-eight medical students volunteered for this research. Students viewed a video on subcuticular suturing then completed a pretest requiring closure of an incision in a plastic model. Students were randomized among 3 groups: practice with an instructional video (group A), practice with supervision by an expert instructor (group B), and independent practice (group C). After instruction, students completed a posttest, then a retention test 1 week later. Their performances were video recorded and evaluated using a validated scoring instrument composed of global and task-specific subscales.

RESULTS

Performances measured using both subscales improved significantly from pretest to post-test only for group B. However, when comparing student performances between pretest and retention posttest, significant improvements on both subscales were seen only in group A.

CONCLUSION

These results suggest that practice with an instructional video is an effective method for acquiring skill in subcuticular suturing.